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Tarsal Tunnel Syndrome

What is the Tarsal Tunnel?

The tarsal tunnel is an area located just behind the medial (inside) ankle bone. There are several structures that run through the tarsal tunnel and this is the main reason it is the most common place of nerve entrapment.

The posterior tibial nerve runs through the tarsal tunnel and then continues to the bottom of the foot, splitting into branches of nerves that are responsible for providing sensation and movement from the bottom of the foot right up to the toes. In tarsal tunnel syndrome, there is an unnatural compression of the posterior tibial nerve and/or its branches which can cause altered sensation through the sole and heel of the foot.

What causes Tarsal Tunnel Syndrome?

Because the area of the tarsal tunnel is so busy, there are many structures that can cause impingement of the nerve. “Flat feet” or pes planus, has been shown to be a significant risk factor when looking at its relation to people who suffer from Tarsal Tunnel Syndrome. The altered alignment of the ankle can cause pressure to be built on the medial side of the ankle, compromising the tarsal tunnel and therefore, the nerve. An injury to the medial ankle can have similar effects, e.g. medial ankle sprain, cystic or tumour growth in the area, varicose veins, muscle and tissue tightness, or inflammation of a tendon in the area can also be the cause.

What Are The Symptoms?

Tarsal tunnel syndrome is a condition that presents with many neural symptoms. Symptoms are aggravated with increased activity and usually settle quickly with rest.

  • Tingling in and around ankles, foot and occasionally the toes.
  • Painful burning, tingling, or numb sensations in the lower legs.
  • Pain radiating up into the leg, and down into the arch, heel, and toes.
  • Burning sensations on the sole of the foot that can radiate up towards the knee.
  • Altered temperature sensation in the feet.
  • A feeling as though the feet do not have enough padding.

How Can Physiotherapy Help?

Conservative Management

Phase 1:

Aim: Decrease inflammation and reduce tissue damage/pain.

  • Avoid aggravating activities.
  • Ice.
  • Taping to de-load injured tissue.
  • Stretching + nerve mobility exercises.
  • Soft tissue release.
  • Joint mobilisations.
  • Neural mobilisation.

Phase 2:

Aim: Achieve full range of motion and increase strength.

  • As above.
  • Tibialis posterior strengthening exercises in non-weight bearing.
  • Gradual increase in resistance through elastic bands.
  • Activity limitation based intervention – working on functional tasks (analysis and modification).

Phase 3:

Aim: Improve functional mobility, regain full range of motion and strength.

  • As above.
  • Progress Tibialis posterior strengthening to weight bearing.
  • Gradually add resistance with additional weight.

The treatment for tarsal tunnel syndrome will depend on the cause. Orthotics are a great way to realign the foot and prevent any excessive rolling in. Anti-inflammatories, rest, and ice may be helpful treatments if the sensation is due to an inflamed structure. When conservative management doesn’t provide adequate respite from symptoms, a surgical approach is recommended.

Surgical management:

The surgical approach can include; decompression of the tibial nerve and its branches, release of deep fascia of the abductor halluces muscle and/or removal of any impinging cysts/growths. Rehabilitation following surgery can be as long as 3 months before full recover, depending on the specifics of the case and procedure.

Post-Op Rehabilitation

Phase 1 – Weeks 1-3

Aim: Protect integrity of the surgical site, reduce inflammation and control pain.

  • Non-weight bearing mobility with crutches.
  • Immobilise joint.
  • Begin passive ROM at joint to protect integrity of joint and avoid excessive joint stiffness.

Phase 2 – Weeks 3-6

Aim: Restore range of motion in joint and begin gait re-education.

  • Mobilise WBAT and progress gait as appropriate (usually with protective splint/brace).
  • Continue passive ROM exercises – progress to active assisted.
  • Active ankle stretches.
  • Tibial nerve mobilisation.

Phase 3 – Weeks 6-12

Aim: Restore normal function and begin work towards activity specific exercise.

  • Progress exercises to include resistance and then body weight – need to be pain free.
  • Continue gait re-education and work towards normal gait mechanics.
  • Work on proprioception and balance training.
  • Begin to progress exercise back into normal routine – working on cardiovascular fitness, activity specific exercise.